Goal-directed therapy (GDT) continues to be a subject of controversy in intensive care medicine, especially after the results of recent trials exploring its effectiveness. Our cover story this issue looks at two aspects of GDT. Azriel Perel addresses some of the remaining questions about the practice of perioperative goal-directed therapy. Despite evidence supporting its routine use, it has not been widely adopted. Perel examines some of the potential reasons for this gap between evidence and practice. Rebekah Thomson and colleagues explain the rationale for the use of GDT after cardiac surgery, and look at the outcomes, practicalities of implementation and cost-effectiveness.
Emanuel Rivers’ contribution on sepsis will be published online shortly after this issue goes to print, to take account of the most recently published clinical trial results. Please visit the ICU Management website to make sure you are signed up for ICU Management Highlights, where this article will feature.
In the last in our Fluids series, David Gattas offers nine compelling reasons to investigate conservative fluid management in intensive care medicine more widely. Gattas asserts that the quality and quantity of clinical fluid science has markedly increased, particularly understanding which fluid to use.
Our Matrix section opens with a paper by Eleni Patrozou and Eirini Christaki on antibiotic management in the ICU. They focus on strategies aimed at optimising antimicrobial use within intensive care units, and explain general principles of antibiotic use in the ICU, including timing, antimicrobial selection, combination therapy, dosing, source control and duration. Next Djillali Annane considers what evidence-based care in the ICU is, and the potential role of big data, adaptive and other innovative designs for clinical trials. Annane concludes that intensivists need to improve the efficiency of methods to generate evidence-based care for the critically ill. Last, Kira Achaibar and Carl Waldmann write about prevention of venous thromboembolism (VTE) in critical care, which can include anti-coagulation therapy, mechanical prophylaxis and IVC filters, ventilator care bundles and critical care rehabilitation. They note that the number of patients receiving adequate thromboprophylaxis is poor currently.
In our Management section, firstly Richard Pugh and colleagues explain the use of frailty measurements in intensive care by summarising the current literature on frailty in the critically ill, and examine the feasibility of implementing a frailty score in clinical practice. They argue that using the Clinical Frailty Scale as a tool to assess patients referred to intensive care might facilitate discussions about treatment aims, and identify patients who are likely to need enhanced support following critical illness. Next, Leo and Simone Nefiodow discuss whether there is a correlation between health and economic growth. They explain that the development of leading industrialised nations is significantly determined by economic cycles: the Kondratieff waves. They argue that the new, sixth Kondratieff wave is the newly emerging second healthcare sector.
Bertrand Guidet, our Interviewee this issue, has a keen interest in elderly care, arguing that the issue of elderly patients is of paramount importance, because intensivists are at the centre of the process, needing to address ethical, financial and organisational issues. He answers questions about this and more areas of his expertise in this issue’s Interview.
We visit Turkey for our Country Focus. M. Necmettin Ünal, President, Turkish Society of Intensive Care (TSIC) and Evren ŞSentürk, Executive committee, TSIC, write about the activities of the Society and the development of intensive care medicine in Turkey since the first ICU was founded in Istanbul in 1959, They continue by writing about hot topics in Turkish intensive care medicine. Since intensive care medicine was recognised there as a supraspecialty in 2009, it has evoked several debates, including the role of directors of ICUs who do not have the Ministry of Health Diploma of Intensive Care. Several solutions have been proposed, however.
As always, if you would like to get in touch, please email [email protected] Jean-Louis Vincent